Ethical and Relational Leadership: How Nurse Managers Address Underperformance in Clinical Practice—A Qualitative Study

AIM: This study explored the experiences of 10 nurse managers when addressing staff underperformance in clinical practice. DESIGN: A qualitative descriptive design was employed to answer the research question. METHODS: Data were collected through in-depth, semi-structured interviews with 10 nurse managers between March and August 2023. Data were analysed using Braun & Clarke's six-stage thematic analysis framework to identify the challenges and strategies nurse managers employed when managing staff underperformance in clinical practice. RESULTS: Four key themes were identified: Proactive Communication, Relational and Ethical leadership, learning on the job and adhering to policy and human resource processes. Collectively, these themes illustrate the complex interpersonal, organisational, and procedural factors that shape nurse managers' experiences when managing underperformance in practice. CONCLUSIONS: The findings indicate that nurse managers integrate ethical and relational leadership approaches to address underperformance in clinical practice. This approach supports constructive performance management while preserving staff dignity and patient safety. Developing these capabilities among nurse managers may strengthen leadership effectiveness and enhance staff accountability. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Empowering nurse managers through training, mentorship, and aligned human resource processes may strengthen performance management practices and ultimately enhance patient safety and care quality. This study contributes empirical evidence to an area where research remains limited, shedding light on the realities nurse managers face when addressing underperformance. IMPACT: The findings from this research offer novel insight into the lived experiences and strategies of nurse managers as they navigate underperformance in clinical practice. The findings can inform the development of effective evidence-based performance management approaches across healthcare settings. PATIENT OR PUBLIC INVOLVEMENT: This study did not include patient or public involvement in its design, conduct, or reporting.